• A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility” section below). • Claims payment, processing, or reimbursement for health care services or supplies. The appeals process ALERT! If your appeal is for an urgent or life-threatening condition, see the "Expedited appeals process" section below. You or someone you authorize to represent you (see “How to designate an authorized representative” on page 148) may submit an appeal. There are three levels to the appeals process: 1. First-level appeal 2. Second-level appeal 3. External review (independent review) Each of those parts are described in further detail below. Coverage during each review If your request involves a decision to change, reduce, or terminate coverage for services, supplies, or prescription drugs already being covered, the plan must continue to cover the disputed service until the outcome of the review. If the plan upholds the decision to change, reduce, or terminate coverage, you will be responsible for the cost of the services received during the review period. If you request payment for denied claims or approval of services, supplies, or prescription drugs not yet covered by the plan, the plan will not cover the services, supplies, or prescription drugs while the appeal is under consideration. First-level and second-level appeal reviewers Claim processing disputes will be reviewed by administrative staff. The plan will consult with a health care professional employed by Regence BlueShield on medical appeals, or with a health care professional employed by Washington State Rx Services on prescription drug appeals, when appeals involve issues requiring medical judgment about covering, authorizing, or providing health care. That includes decisions based on determinations that a treatment, prescription drug, or other item is experimental, investigational, or not medically necessary. Your appeal will be reviewed by Regence BlueShield or Washington State Rx Services employees who have not been involved in, or subordinate to anyone involved in, reviewing the previous decisions. How to submit an appeal You or your authorized representative (including a relative, friend, advocate, attorney, or provider) may submit an appeal by using the methods described below in the “Where to send complaints or appeals” section. You may authorize a representative to submit an appeal on your behalf in writing or by contacting UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals). For each appeal request, you must appeal within 180 days of receiving the plan’s decision. You may include written comments, documents, and any other information, such as medical records and letters from your provider, to support your appeal request. The plan will consider all information submitted when reviewing your appeal. You may also request copies of documents the plan has that are relevant to your appeal, which the plan will provide at no cost to you. 138 2024 UMP Classic (PEBB) Certificate of Coverage